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Chronic care management can lead to reduced spending for Medicare beneficiaries. CMS’s new code lets health care organizations be more fully reimbursed for these services.

Navigating health reform

New CMS Code Allows Reimbursement for Non-Face-to-Face Care Coordination

  • 4/30/2015

Earlier this year The Centers for Medicare and Medicaid Services (CMS) provided an opportunity for physicians and health systems to get a glimpse of the future of health care reimbursement, and essentially “test drive” it before it becomes a reality. They did this by creating a current procedural terminology (CPT) code for chronic care management (CCM) services that will provide physicians with additional reimbursement if they meet certain requirements. The concept of this CPT code is directly in line with the desired evolution of health care to manage the health of a population of people.

Transitioning to the CCM model of care will require rethinking how care is delivered and moving away from physician-led care to physician-led care teams.

Reimbursing for care management

CMS has long recognized that care management is a critical component to primary care services that, when delivered effectively, will lead to improved health and reduced spending for Medicare beneficiaries. Until January 1, 2015, however, the reimbursement system did not effectively reimburse physicians for care management services that took place outside of a traditional face-to-face visit. Physicians and other practitioners are now eligible to be reimbursed for non-face-to-face care coordination activities by using CPT code 99490 when they meet specific eligibility criteria. The total reimbursement for these care coordination activities would amount to about $43 per eligible beneficiary per month. While this may not sound significant on the surface, it can add up. At the same time, the motivation for the reimbursement — rewarding effective care management — can lead to improved patient outcomes and experiences.

Qualifying for reimbursement

In order to qualify for the additional reimbursement, physicians and the Medicare beneficiary receiving the service must meet specific criteria. A high level overview of those requirements is as follows:

  1. At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional must be spent on care management per calendar month.
  2. The beneficiary must have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient.
  3. The chronic conditions put the patient at significant risk of death, acute exacerbation or decomposition, or functional decline.
  4. A comprehensive care plan must be established for the patient, and this plan must be implemented, monitored, and revised as necessary.
  5. The patient must have access to the physician or other qualified member of the health team 24 hours per day, 7 days per week.
  6. The patient must be informed that CCM services will be provided, and sign a consent form to authorize sharing of medical information with other providers.

CMS has provided an example of the types of chronic conditions that could potentially allow the use of CPT code 99490. They include:

  • Alzheimer’s disease and related dementia
  • Arthritis
  • Asthma
  • Cancer
  • Diabetes
  • Depression
  • Hypertension
  • Chronic obstructive pulmonary disease

Who is eligible to bill for services?

To support the implementation of care coordination activities, CMS provided exceptions to Medicare’s “incident to” rules that allows certain clinical staff to provide CCM services under the general supervision — rather than direct supervision — of the billing physician. According to CMS, physicians and the following practitioners are eligible to bill for CCM services:

  • Physician assistants
  • Nurse practitioners
  • Clinical nurse specialists
  • Certified nurse midwives

Business case considerations

In any transformation it is important to understand not only the clinical requirements and benefits, but also the impact on the organization from a reimbursement and financial perspective.

Sample Business Case for CCM Services
Unique patient panel size
Medicare percentage
Unique Medicare patients
Percent with multiple chronic conditions
Medicare patients potentially eligible for CCM reimbursement 231
Medicare patients potentially eligible for CCM reimbursement
CCM physician fee schedule reimbursement rate
Monthly reimbursement
Annual reimbursement
Hours/month to meet CCM requirements 77

To evaluate the business case for considering CCM services, we completed an analysis that assumes a patient panel size of 2,000 patients. Of that total patient population, we assumed 35 percent were Medicare beneficiaries, and that 33 percent of those Medicare beneficiaries would be eligible for CCM services due to multiple chronic conditions and meeting the CMS criteria. Based on these assumptions, about 231 patients would be eligible to receive CCM services, for which the practitioner delivering those services would receive reimbursement of just over $118,000 on an annual basis.

The team assembled to provide CCM services would have to spend a minimum of 20 minutes per month for each patient, or just under 80 hours per month on the 231 patients.

What should you do?

CCM services represent a real opportunity for those willing to embrace the health care transition taking place. While there are many details to understand and processes to implement, one thing is for sure — CMS has created an opportunity for practitioners to be reimbursed for non-face-to-face care coordination services.

So what must be done in order to capitalize on these opportunities? Using our illustration above, it would be impossible to expect physicians to dedicate 80 hours per month to direct care coordination activities. Transitioning to the CCM model of care will require rethinking how care is delivered and moving away from physician-led care to physician-led care teams.

CLA has extensive experience in analyzing the reimbursement implications associated with CCM services and physician-led clinical care teams. We have the operational expertise to guide your organization through assessment to implementation. If you want to learn more and are ready to take the next steps, CLA can help your organization make this important transformation.